Very high rates of retention in care and undetectable viral loads are possible in U.S. clinics providing care for disenfranchised people living with HIV in urban centers, according to a new study and accompanying editorial published online ahead of print by Clinical Infectious Diseases (CID). The Johns Hopkins HIV Clinic cohort study's findings are highly relevant for the HIV community, the editorial suggests, “because they show extremely high treatment success rates, even in the context of challenging sociodemographic circumstances.”

A landmark study highlighting discrepant outcomes between clinical trials and clinical practice was a retrospective review of 237 people receiving initial protease inhibitor–based treatment from 1996 to 1998 at Johns Hopkins, explains Paul Sax, MD, of Boston's Brigham and Women's Hospital in his CID editorial. The cohort consisted predominantly of an inner-city, relatively poor and largely African-American population. Only 37 percent achieved undetectable viral loads one year after beginning therapy—about half the rate of treatment efficacy achieved in clinical trials using the same antiretroviral (ARV) agents.

“The results of this study were sobering and had a major impact on clinical practice,” Sax writes. “Providers were understandably leery of prescribing [ARV therapy] to patients who had such a low rate of treatment success, because virologic failure could select for HIV drug resistance mutations that both reduced future treatment options for the individual and, ominously, could be transmitted to others. The increased recognition of severe metabolic abnormalities and disfiguring body shape changes—sometimes correctly and sometimes incorrectly linked to [ARV treatment]—pushed the favored treatment strategy from a ‘hit early, hit hard' approach to one in which clinicians could feel justified counseling patients to avoid starting therapy for as long as possible.”

The more recent results, reported by Richard Moore, MD, and John Bartlett, MD, involving the same cohort, are a “remarkable accomplishment,” the authors write.

Since 1996, Moore and Bartlett report, the proportion of people living with HIV being retained in care at the clinic has increased from 86 percent to 94 percent. The rate of those receiving ARV therapy has also increased, from 22 percent in 1996 to 85 percent in 2010.

While the average viral load among the clinic patients was 10,000 copies in 1996, it was below 200 in 2010. In fact, only 17 percent had viral loads above 500 in 2010, which included patients  both on and off ARV treatment.

CD4 counts were also much improved, increasing from an average of 239 in 1996 to 444 in 2010.

“We believe that our results emphasize that even in an inner urban HIV-infected population with a relatively high proportion of patients who were infected as a consequence of injection drug use, [ARV therapy] can be highly successful,” Moore and Bartlett conclude.

“One potential explanation for these extraordinary results is that Johns Hopkins has been a longstanding leader in HIV care and research, with a well-established multidisciplinary HIV program,” Sax writes. “Although the care given is undoubtedly excellent…it is important to emphasize that this improvement in outcomes is also occurring at other sites; the authors fully acknowledge that they cannot take full credit.”